Almost every day, one of our hospital clients refers a case to our firm that has us questioning how an insurer could have reached the decision they did.

We got a unique look into the inner workings of Aetna’s utilization management department this week with the bombshell revelation, reported by CNN, that a former Aetna Medical Director, Dr. Jay Ken Iinuma admitted in a deposition that he never looked at a patient’s medical records during his time at Aetna.

What’s worse? Dr. Iinuma further testified that this was what he was instructed to do in Aetna’s training for the position.

The State of California’s insurance commissioner has launched an investigation into the practice, and we expect other states to follow. Not only does this practice raise serious questions about the plan’s adherence to member agreements to cover medically necessary care, but it may run afoul of state regulations requiring that utilization review be performed by a qualified medical professional.

What should medical professionals do with this information? It is a good practice to have a robust denials management system in place at your practice or facility. Take advantage of peer-to-peer review rights and file appeals. Keep an eye on timeframes, as a lot of contracts take away an opportunity to challenge even egregious denials after these timeframes pass.

At Fotheringill & Wade, some effective strategies we employ include:

Checking the credentials of the person at the insurer who made the decision. Was it a medical professional? Does the contract or state law provide for a doctor versus a nurse to issue the denial? Can we discount the insurer’s position by noting that the reviewer has no experience in the patient’s condition?

Finding the insurers’ clinical policy and referring directly to it. It is effective, though time-consuming, to match medical record citations with clinical policy prongs. Did the insurer use the correct policy for the patient’s condition to issue its denial? Assume (and now we have reason to!) that the doctor isn’t taking even a cursory glance at the medical records.

Pushing back when a denial is egregious. Complain! Take the matter to your provider representative; talk to the plan’s compliance department or legal counsel. Take advantage of external appeals. Don’t take “no” for an answer when the plan seems to be ignoring the words on the page.

As with all things, experience counts. We have a great track record of helping our hospital clients with insurance denials. If you are struggling with insurance denials, you aren’t alone! Contact us to discuss your insurance denial management.